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NURS 222 STUDY GUIDE WITH COMPLETE SOLUTION ANSWERED PERFECTLY!!
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NURS 222 STUDY GUIDE WITH COMPLETE SOLUTION ANSWERED PERFECTLY!!
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NURS 222 STUDY GUIDE WITH COMPLETESOLUTION ANSWERED PERFECTLY!!
palpating systolic BP
answers: Useful for patients whose arterial pulsations are too weak to create
Korotkoff sounds (i.e. severe blood loss, decreased
contractility). Assess only systolic blood pressure (SBP) by palpation, not diastolic
blood pressure (DBP)
VIRTUAL SKILLS STACK: PALPATION BP MEASUREMENT
answers: - Position cuff 2.5 cm above palpated brachial artery with arrows
centered over artery
- Palpate radial artery while inflating cuff to determine systolic
pulse pressure (disappearance of radial pulse)
- Deflate cuff
- Palpate radial artery while inflating cuff to 30 mmHg above point
where pulse disappears
- Slowly deflates cuff & notes pressure at which the radial artery
pulse returns (verbalizes this is palpated systolic BP)
- Removes cuff
- Performs hand hygiene
HEART ASSESSMENT
answers: - Assessment technique: Inspection, Palpation, Auscultation
- Equipment: Stethoscope
- Locate landmarks
- Placement of stethoscope
,- Auscultate heart sounds (anterior thoracic cavity)
precordium
answers: thorax to heart which sits behind sternum, heart points to right rib 1-2,
second intercostal space to fifth
apex
answers: bottom of the heart
Base
answers: top of the heart
ANTERIOR THORACIC CAGE: LANDMARKS
answers: suprasternal notch, angle of louis, sternum
4 auscultation areas
answers: aortic valve area (2nd intercostal space (ICS) at the right sternal border
(base of the heart)), pulmonic valve area (2nd ICS at the left sternal border (base of
the heart), erb's point (third left intercostal space (left sternal border)), Tricuspid
Valve Area (4th ICS at the left lower sternal border), Mitral (apical) Valve Area
(5th ICS at or around the left midclavicular line, the apex of the heart)
Aortic Value Area
answers: 2nd intercostal space (ICS) at the right sternal border, base of the heart
Pulmonic Valve Area
answers: 2nd ICS at the left sternal border, base of the heart
,Tricuspid Valve Area
answers: 4th ICS at the left lower sternal border
Mitral (apical) Valve Area
answers: 5th ICS at or around the left midclavicular line, the apex of the heart
Semilunar valves
answers: separate ventricular from arteries, aortic/pulmonary
AV valves
answers: connect the atrium to the ventricles and include the mitral valve as well
as the tricuspid valve
AUSCULTATORY SITES acronym
answers: APE (aortic, pulmonic)
TO (tricuspid)
Man (mitral)
or
All Patients Take Medicine
HEART SOUNDS: S1 "LUB"
answers: - First heart sound
- Signals beginning of systole
- Closure of *AV* valves causes sound
- Corresponds with each carotid pulsation
, - Loudest at the *apex* of the heart
HEART SOUNDS: S2 "DUB"
answers: - Second heart sound
- Starts diastole
- Closure of *semilunar* valves causes sound
- Loudest at the *base* of the heart
cardiac cycle and heart sounds
answers: Diastole (slow, filling / rapid filing) = DUB, systole (ejection) = LUB
(isometric contraction)
AUSCULTATION OF HEART SOUNDS: DIAPHRAGM OR BELL?
answers: - Use the *diaphragm* of the stethoscope to listen for high pitch
sounds, such as breath sounds, *normal heart sounds*, bowel
sounds, press the diaphragm *firmly* against the body part being auscultated.
- Use the *bell* of the stethoscope to listen to low pitched sounds
such as *abnormal heart sounds*. Hold the bell *lightly* on the
body part being auscultated.
HEART ASSESSMENT DOCUMENTATION
answers: - Heart sounds: S1, S2
- Rate: Eucardia, Tachycardia, Bradycardia
- Rhythm: Regular or Irregular
measuring apical pulse
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